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Preoperative and Intraoperative Lymphatic Mapping for Radioguided Sentinel Node Biopsy in Cancers of the Female Reproductive System

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Atlas of Lymphoscintigraphy and Sentinel Node Mapping

Abstract

Sentinel lymph node is the first lymph node with direct lymphatic drainage from the primary tumor, so it can predict the overall lymph node status. Sentinel lymph node biopsy is recommended as the standard of care for well-selected women with early-stage vulvar cancer (stages IB and II), cervical cancer (stage IA1 with lymphovascular invasion, stages IA2, IB1, and IIA1), and endometrial cancer (stages IB and II). The combination of radiotracer and blue dye is nowadays the most appropriate technique for sentinel lymph node mapping, especially for cervical cancer. There is a growing interest for hybrid tracer known as indocyanine green-99mTc-nanocolloid in vulvar cancer and cervical cancer. SPECT/CT imaging enables to personalize lymphatic mapping, providing detailed information about the number and anatomical location of sentinel lymph nodes for adequate surgical planning. Sentinel lymph node biopsy in patients with cancers of the female reproductive system should be performed in experienced, tertiary referral centers.

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Acknowledgements

This chapter is a revision of the original chapter written by P. Paredes and S. Vidal-Sicart in the previous edition of the book.

Author information

Authors and Affiliations

  1. Nuclear Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

    Angela Collarino

  2. Institute of Nuclear Medicine, Università Cattolica del Sacro Cuore, Rome, Italy

    Annalisa Zurru

  3. Nuclear Medicine Department, Hospital Clinic Barcelona, Barcelona, Catalonia, Spain

    Sergi Vidal-Sicart

  4. Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Catalonia, Spain

    Sergi Vidal-Sicart

Authors
  1. Angela Collarino
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  2. Annalisa Zurru
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  3. Sergi Vidal-Sicart
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Corresponding author

Correspondence to Angela Collarino .

Editor information

Editors and Affiliations

  1. Regional Center of Nuclear Medicine Department of Translational Research and Advanced Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy

    Giuliano Mariani

  2. Nuclear Medicine Department, Hospital Clinic Barcelona, Barcelona, Catalonia, Spain

    Sergi Vidal-Sicart

  3. Department of Radiology Section of Nuclear Medicine and Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands

    Renato A. Valdés Olmos

Clinical Cases

Clinical Cases

Case 14.1 SLN Mapping in Vulvar Carcinoma: False-Positive Finding Due to Lymphatic Duct

Alberto Fragano Danilo Fortini Luca Zagaria

Background Clinical Case

A 73-year-old woman with two foci of invasive vulvar squamous cell carcinoma located in both left and right labia minora. She was scheduled for radical vulvectomy and bilateral SLNB.

Lymphoscintigraphy

Fig. 14.6
figure 6

After the application of local anesthesia, 99mTc-nanocolloid (four aliquots of 74 MBq in 0.2 mL) was injected around the two lesions the day before the surgery (2-day protocol). The anterior dynamic (a) and early (b) images show unilateral lymphatic drainage with visualization of two SLNs (arrows, b) in the left groin. The anterior late image (c) shows bilateral lymphatic drainage with only one SLN (arrow) in the left groin corresponding to a single focal uptake (yellow arrow) on transaxial SPECT/CT image (d) and a non-enlarged lymph node (yellow arrow) located in the medial superior inguinal zone on transaxial low-dose CT (e). In conclusion, the two foci of uptake defined as SLNs in the left groin at dynamic and early planar images correspond to one SLN and to its lymphatic vessel on transaxial fused SPECT/CT image, respectively

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Case 14.2 SLN Mapping in Vulvar Carcinoma: Visualization of Pelvic SLN

Alberto Fragano Danilo Fortini Germano Perotti

Background Clinical Case

An 82-year-old woman who had a vulvar squamous cell carcinoma of clitoris. She was scheduled for radical vulvectomy and bilateral SLNB.

Lymphoscintigraphy

Fig. 14.7
figure 7

After the application of local anesthesia, 99mTc-nanocolloid (four aliquots of 37 MBq in 0.1 mL) was injected around the tumor the same day of the surgery (1-day protocol). The anterior dynamic images (a) show bilateral lymphatic drainage with one SLN in the right groin (arrow) corresponding to one focal uptake (red arrow) on transaxial SPECT/CT image (b) and non-enlarged lymph node (red arrow) in the medial superior zone on transaxial low-dose CT (c), plus another focal uptake in the pelvic area (yellow dashed arrow, d) corresponding to a non-enlarged lymph node (yellow dashed arrow) located in the external iliac zone on transaxial low-dose CT (e)

Full size image

Case 14.3 SLN Mapping in Cervical Cancer: Visualization of Para-aortic SLN

Sergi Vidal-Sicart Andrés Perissinotti Sebastian Casanueva

Background Clinical Case

A 34-year-old woman who had early-stage cervical cancer (stage IB1).

Lymphoscintigraphy

Fig. 14.8
figure 8

After peritumoral injection of 111 MBq of ICG-99mTc-nanocolloid in four deposits of 0.5 mL each (a), anterior planar images were obtained at 30 min (early imaging, b) and 120 min (late imaging, c). A focal uptake in the para-aortic area (red arrow) was clearly seen in the early image (b), and was considered as para-aortic SLN. Coronal CT image with 3D volume rendering (d) shows the depicted SLN with the surrounding anatomical structures. It is unusual to find para-aortic SLNs after radiotracer injection into the uterine cervix. Para-aortic nodal spread occurs usually orderly, with progressive involvement of the pelvic and common iliac lymph nodes before para-aortic lymph nodes. However, cervical cancer can occasionally metastasize directly to the para-aortic lymph nodes by embolization of the posterior lymphatic pathway (presacral area). Just before surgery, 2 mL of methylene blue dye was injected in the same site as the radiotracer. During laparoscopy (e), a net of blue-stained lymphatic channels (blue arrows) were depicted running upwards to the para-aortic SLN. This SLN was excised and exhibited radioactivity (150 cps/s), fluorescence (f), and blue color. Histopathology did not show metastatic involvement in this, nor in two additional SLNs located in the pelvis

Full size image

Case 14.4 SLN Mapping in Endometrial Cancer

Sergi Vidal-Sicart Andrés Tapias Sebastian Casanueva

Background Clinical Case

A 70-year-old woman who had endometrial carcinoma with myometrial involvement >50% of the uterine wall thickness.

Lymphoscintigraphy

Fig. 14.9
figure 9

After injection of 185 MBq of hybrid tracer (ICG-99mTc-nanocolloid) in the myometrial tissue guided by transvaginal ultrasound, early (at 30 min, a) and late (at 120 min, b) images were obtained. The deep injection in the myometrial area results in fast diffusion into the bloodstream with ensuing early visualization of the bone marrow that can hinder visualization of lymph nodes. Only one area of focal uptake in the right pelvic area was seen at early (a) and late (b) planar imaging, and was considered as a pelvic SLN. Coronal CT images with 3D volume rendering (c) and their corresponding transaxial CT images (d, e) show a second focal uptake in the left pelvic side (red arrow, d) corresponding to a second SLN in the left obturator fossae. During surgery, only the left SLN was resected. No activity was observed with the laparoscopic adapted gamma probe nor fluorescence was detected in the right pelvic area. Histopathology revealed metastasis of the resected left SLN. Pelvic lymphadenectomy resulted in harvesting of 12 negative lymph nodes and 1 positive node in the left side, and only 5 negative lymph nodes in the right pelvis

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Collarino, A., Zurru, A., Vidal-Sicart, S. (2020). Preoperative and Intraoperative Lymphatic Mapping for Radioguided Sentinel Node Biopsy in Cancers of the Female Reproductive System. In: Mariani, G., Vidal-Sicart, S., Valdés Olmos, R. (eds) Atlas of Lymphoscintigraphy and Sentinel Node Mapping. Springer, Cham. https://doi.org/10.1007/978-3-030-45296-4_14

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  • DOI: https://doi.org/10.1007/978-3-030-45296-4_14

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